Childhood trauma is a major cause of mortality and morbidity, disability and socio-economic burden.
Hester Langeveld is a general surgeon, trained in the Netherlands, with interest in paediatric surgery. She temporarily works as a supernumary registrar at the Trauma Unit, Red Cross War Memorial Children’s Hospital, Cape Town, and is involved in research on blunt abdominal trauma.
Sebastian van As heads the Trauma Unit at Red Cross War Memorial Children’s Hospital in Cape Town. He has been active in a wide range of national and international research projects, educational initiatives and advocacy roles on child safety initiatives regarding child injuries as well as child abuse.
Correspondence to: Sebastian van As (Sebastian.firstname.lastname@example.org)
The global burden of childhood injuries
The World Report on Child Injury Prevention
was published by the WHO and UNICEF in 2008. The report regards
child injuries and deaths as a major public health problem
requiring urgent attention.1 Childhood
injury and violence are the predominant killers of children
throughout the world; it is estimated that they are responsible
for the death of approximately
1 million children under the age of 18 years annually. Accidental injuries account for the vast majority (90%) of these cases, while the remainder (10%) is estimated to be due to violence or maltreatment.
So, every day more than 2 000 children and teenagers die from an injury which could have been prevented. Road traffic injuries alone are the leading cause of death among 15 - 19-year-olds and the second leading cause among 10 - 14-year-olds. In addition, tens of millions of children require hospital care for their injuries and many of them are left with a degree of disability.2 It is estimated that over 95% of all deaths due to injury in children occur in low- and middle-income regions and countries. Although the child injury death rate is much lower among children from developed countries, injuries are still a major cause of death, accounting for about 40% of all child deaths.
Imaging: What’s new?
Radiological imaging represents a significant part of the diagnostic process in paediatric trauma. Physical examination can be difficult, in particular in small children, but also because a high proportion of the injured children are poly-traumatised, often with associated head injury. Childhood tissues are more vulnerable than those of adults to the effects of radiation, predisposing to malignancies in later life.3 , 4 Therefore radiation doses should be kept as low as possible, while maximising the detection of injuries. Increasing awareness of the risk of radiation-induced malignancy has led to the search for alternative diagnostic strategies.5
The development of the total body digital imaging device with slot scanning technology (Lodox®) has been able to lower the radiation dose with a minimal amount of scattered radiation, enabling parents or caretakers to remain in close proximity of the child that is being imaged. This new type of total-body scanning with low radiation has revolutionised diagnostics of injured children.6 , 7
Emergency ultrasound or focused abdominal sonography for trauma (FAST)
The use of ultrasonographic modalities in the assessment of trauma in children is gaining popularity. Data from a 2008 survey of children’s hospital emergency departments in the USA showed that only 60% were using emergency ultrasound for managing paediatric patients.8 The last several years, however, there has been a marked increase in the literature regarding the use of emergency ultrasound in paediatric patients.9 And as of 2011, nearly all paediatric emergency departments in the USA use emergency ultrasound.8 Ultrasound in trauma patients can be used, for example, for identifying clavicle or femur fractures or guiding fracture reduction.11 , 12 , 18 Bedside emergency ultrasound further accurately diagnoses paediatric skull fractures with positive and negative predictive values of 97.2% and 100% respectively when compared with a CT scan.21 For blunt abdominal trauma a CT scan of the abdomen with intravenous and enteral contrast has been the standard of care for the evaluation of the peritoneal cavity and the retroperitoneum. The FAST scan is a 4-view scan reliant on detecting the presence of fluid within the most dependent zones of the peritoneum in the horizontal patient and pericardium. It is capable of detecting more than 100 - 250 ml of free fluid.22 Abdominal ultrasound has a modest sensitivity for the detection of haemoperitoneum in children with blunt abdominal trauma; therefore a negative ultrasound examination has questionable utility as the sole diagnostic test to rule out intra-abdominal injury. However, a positive ultrasound examination in a haemodynamically stable child should lead immediately to abdominal computed tomographic scanning because of the high risk of intra-abdominal injury.23
Use of minimally invasive surgery in paediatrics developed more gradually than in general surgery.24 However, today its role is well established and indications are increasing daily. Laparoscopy in paediatric trauma is a safe method for the evaluation and treatment of selective blunt and penetrating abdominal injuries in haemodynamically stable patients.25 Laparoscopy serves as a diagnostic tool in abdominal trauma, which reduces the morbidity of a negative laparotomy.26 Laparotomy, however, remains the gold standard for diagnosis and treatment of injuries in a child with haemodynamic instability. The operation is not without risks, including a 20% morbidity rate, 0 - 5% mortality, and a 3% long-term risk for bowel obstruction.27 , 28
Management – what’s new?
Non-operative management of abdominal injuries
Management of paediatric abdominal trauma has evolved over the last four decades. Current strategies of non-operative management for most (90%) blunt solid organ injuries developed out of the observation that most solid organ injuries would ‘heal themselves’ and that operative intervention could indeed interfere with this process.29 Organs most commonly injured are the liver and spleen, followed by kidney, pancreas and hollow viscera. Prescription during the admission process includes intravenous maintenance fluids, appropriate analgesia and a nil per os regimen, as well as bedrest for a ‘clinically appropriate’ duration. The setting of the care, i.e. whether in a high care/intensive care or ward environment, will be dictated by the clinical and metabolic condition of the patient, as well as by associated injuries, particularly intracranial pathology. In 2000 the American Paediatric Surgical Association published guidelines for length of hospital admission and restriction of activity based on the radiological grade of injury.30 The current trend is for significantly shorter periods of both bedrest and hospitalisation.
Another trend in surgery is early enteral feeding. Enteral nutrition is associated with preservation of gastrointestinal (GI) mucosal integrity, attenuation of the stress response to shock and injury and maintenance of normal GI tract flora.31 The majority of treatment failures occur within the first 12 hours. Most of these can be managed outside the acute period and, in addition, many interventions will be performed percutaneously and endoscopically, avoiding open exploration.24 Despite their delayed intervention, the long-term outcome of this group of patients is not compromised, with the added benefit that they are spared the insults of early surgery. Follow-up imaging is on an individual basis.
Laparoscopy for management of organ injuries
Minimally invasive surgery (laparoscopy) has not only been utilised for diagnosis but has also been performed for the management of complications following conservative management of solid organ injuries. Splenic cysts which do not resolve over time can be treated with partial splenic decapsulation. Bile leaks following liver injuries can occur in up to 6% of patients and can usually be treated with endoscopic retrograde cholangio-pancreaticography (ERCP) and stent placement, accompanied by external drainage of bile collections. Laparoscopic guided external drainage of loculations can be useful for correct positioning of intra-abdominal drains. Where minimally invasive surgery has been slow to gain popularity in paediatric surgical practice, improved equipment and instrumentation suitable for children means that more complex cases can be treated successfully today. General benefits of minimally invasive surgery include less postoperative pain and shorter hospital stay.24
Management of brain injuries
Recognition of the heterogeneity of head injury and the growing appreciation of the role of secondary injury (brain swelling, insults, hypoxia) are important in determining outcome. A modern approach is to identify patients who are not responding adequately to medical measures for reducing intracranial pressure early and to perform an adequate controlled decompressive craniectomy while avoiding hypertension in the postoperative phase. When these guidelines are adhered to, decompressive craniectomy can markedly reduce the intracranial pressure and improve brain oxygenation.32
The future and the importance of preventing childhood injuries
The public health approach requires that we view child injuries similarly to any other disease or health problem,33 and that injuries are predictable rather than random events. By utilising a combination of strategy (the four Es of injury control: Education, Enforcement, Engineering and Environment) modification, the incidence of violent injuries can be reduced. It is very likely that a large percentage of the so-called accidental injuries of children are actually outcomes of certain types of abuse. Over the last few years we have witnessed a medical strive to improve trauma care in nearly all countries. However, the time has now arrived that paediatric care providers, and in particular paediatricians and paediatric surgeons, should unite to establish a proper foundation on which future preventive strategies can be built. By actively promoting child safety we will not only achieve a most welcome reduction in medical costs and disability, but a much-desired decrease in avoidable childhood misery and suffering.
In a nutshell
• Childhood trauma will be the number 1 disease globally in 2020 as expected by the World Health Organization (WHO), who published their third World Report on Child Injury Prevention in December 2008.
• Trauma in children has become a major cause of mortality and morbidity, disability and a socio-economic burden.
• The magnitude of paediatric trauma worldwide was reviewed with additional developments and trends in paediatric trauma.
• Paediatric trauma is a growing field of clinical expertise.
• New developments in imaging and management are discussed: total body digital imaging, emergency ultrasound, diagnostic laparoscopy, targeted management of head injuries, conservative management of abdominal injuries in children, and the laparoscopic management of complications following the conservative management of solid organ injuries.
• Child injuries should be looked at similarly to any other disease or health problem. Paediatric trauma has long been neglected by the medical profession.
• Nowadays, however, awareness is growing, as evidenced by a marked increase in the literature on diagnostics and management in paediatric trauma. Focus should be on primary (preventing the injury), secondary (dealing with the injury in the most efficient manner) as well as tertiary prevention (making sure that children treated for trauma will be appropriately reintegrated within our society).
• By actively promoting child safety we will not only achieve a most welcome reduction in medical cost and disability, but also the ever-so-much desired decrease in avoidable childhood misery and suffering.
1. Peden M, Oyegbite K, Ozanne-Smith J, et al. World Report on Child Injury Prevention. Geneva: WHO and UNICEF. http://www.who.int/violence_injury _prevention/child/en/ (accessed 14 December 2012).
2. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R. World Report on Violence and Health. Geneva:World Health Organization; 2002.
3. ICRP. 1990. Recommendations of the International Commission of Radiological Protection. Ann ICRP 1991;21:1-201.
4. Ron E. Ionizing radiation and cancer risk: Evidence from epidemiology. Pediatr Radiol 2002;32:232-237.
5. Holmes JF, Gladman A, Chang C. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007;42(9):1588-1594. [http://dx.doi.org/10.1016/j.jpedsurg.2007.04.023]
6. Van As AB, Douglas TS, Kilborn T, Pitcher R, Rode H. Multiple injuries diagnosed using full-body digital x-ray. J Pediatr Surg 2006;41:e25-28.
7. Douglas TS, Sanders V, Pitcher R, Van As AB. Early detection of fractures with low-dose digital x-ray images in a pediatric trauma unit. J Trauma 2008;65:E4-7.
8. Marin JR, Zuckerbraun NS, Kahn JM. Use of emergency ultrasound in United States Pediatric Emergency Medicine Fellowship Programs in 2011. JUM 2012;31:1357-1363.
9. Bair AE, Rose JS, Vance CW, Andrada-Brown E, Kuppermann N. Ultrasound-assisted peripheral venous access in young children: a randomized controlled trial and pilot feasibility study. West J Emerg Med 2008;9:219-224.
10. Chen L, Hsiao A, Langhan M, Riera A, Santucci KA. Use of bedside ultrasound to assess degree of dehydration in children with gastroenteritis. Acad Emerg Med 2010;17:1042-1047.
11. Chien M, Bulloch B, Garcia-Filion P, Youssfi M, Shrader MW, Segal LS. Bedside ultrasound in the diagnosis of pediatric clavicle fractures. Pediatr Emerg Care 2011;27:1038-1041.
12. Cross KP, Warkentine FH, Kim IK, Gracely E, Paul RI. Bedside ultrasound diagnosis of clavicle fractures in the pediatric emergency department. Acad Emerg Med 2010;17:687-693.
13. Doniger SJ, Ishimine P, Fox JC, Kanegave JT. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care 2009;25:154-159.
14. Le A, Hoehn ME, Smith ME, Spentzas T, Schlappy D, Pershad J. Bedside sonographic measurement of optic nerve sheath diameter as a predictor of increased intracranial pressure in children. Ann Emerg Med 2009;53:785-791.
15. Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics 2008;121:e1404-e1412.
16. Longjohn M, Wan J, Joshi V, Pershad J. Point-of-care echocardiography by pediatric emergency physicians. Pediatr Emerg Care 2011;27:693-696.
17. Marin JR, Alpern ER, Panebianco NL, Dean AJ. Assessment of a training curriculum for emergency ultrasound for pediatric soft tissue infections. Acad Emerg Med 2011;18:174-182.
18. Patel DD, Blumberg SM, Crain EF. The utility of bedside ultrasonography in identifying fractures and guiding fracture reduction in children. Pediatr Emerg Care 2009;25:221-225.
19. Tsung JW, Raio CC, Ramirez-Schrempp D, Blaivas M. Point-of-care ultrasound diagnosis of pediatric cholecystitis in the ED. Am J Emerg Med 2010;28:338-342.
20. Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Acad Emerg Med 2010;55:284-289.
21. Parri N, Crosby BJ, Glass C, et al. Ability of emergency ultrasonography to detect pediatric skull fractures: A prospective, observational study. J Emerg Med 2012;10:(e-pub ahead of print).
22. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma 1995;39:375-380.
23. Schonfeld D, Lee LK. Blunt abdominal trauma in children. Curr Opin Pediatr 2012;24(3):314-318.
24. Numanoglu A. Laparoscopy in abdominal trauma. CME 2010:28(3):119-121.
25. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg 2007;42(9):1588-1594.
26. Feliz A, Shultz B, McKenna C, Gaines BA. Diagnostic and therapeutic laparoscopy in pediatric abdominal trauma. J Pediatr Surg 2006;41(1):72-77.
27. Ross SE, Dragon GM, O'Malley KF, et al. Morbidity of negative celiotomy in trauma. Injury 1995;26:393-394.
28. Shih HC, Wen YS, Ko TJ, et al. Noninvasive evaluation of blunt abdominal trauma: prospective study using diagnostic algorithms to minimize nontherapeutic laparotomy. World J Surg 1999;23:265-270.
29. Gaines BA. Intra-abdominal solid organ injury in children: Diagnosis and treatment. J Trauma 2009;67:135-139.
30. Stylianos S. Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury: The APSA Trauma Committee. J Pediatr Surg 2000;35:164-169.
31. Weissenfluh GM, Brundage SI, Spain DA. Early enteral nutrition after abdominal trauma: effects on septic morbidity and practicality. Nutr Clin Pract 2006;21(5):479-484.
32. Figaji AA, Fieggen AG, Argent AC, LeRoux PD, Peter JC. Intracranial pressure and cerebral oxygenation changes after decompressive craniectomy in children with severe traumatic brain injury. Acta Neurochir Suppl 2008;102:77-80.
33. Matzopoulos R, Bowman B. Violence and children in South Africa. In: Van As AB, Naidoo S, eds. Paediatric Trauma and Child Abuse. Cape Town: Oxford University Press, 2006:19-28.
Full text views: 5221